VISITATION CHECKLIST/SUMMARY

(R. 5/04)

DATE______TIME______LOCATION______

Employee Making Observation/Recording______

Case Name______Case Number______
Child’s Name ______
Person(s) Visiting/Relationship to Child ______

CHECK IF APPLICABLE

Parent initiates contact
Child initiates contact
Parent and child hug each other
Parent and child kiss each other
Siblings interact with each other appropriately
Parent initiates communication
Child initiates communication
Parent smiles at child
Child smiles at parent
Parent and child have eye contact
Parent listens to child’s communication
Parent uses reasonable tone of voice with child
Parent talks positively about child’s interim placement
Parent asks child about everyday activities (school, play, etc.)
Parent praises and encourages child
Parent lets child know what child is allowed and not allowed to do
Parent sets and communicates age appropriate consequences for behaviors not allowed in ways child understands
Parent manages behavior without punishment
Parent encourages good behaviors
Parent follows through with consequences for behaviors not allowed
Parent talks realistically and makes realistic promises to child
Parent follows through on promises previously made
Child responds appropriately to parent’s direction
Parent is attentive to child’s needs (diaper, dress, bottle, food, bathroom, etc.)
Parent is interested and asks about child’s health and other basic daily needs
Child appears/expresses he/she is excited/happy to visit (before and/or after visit)
Parent provides hope and reassurance at end of visit for the next scheduled visit /

COMMENTS

How did the Parent respond to the child?

How did the child respond to the parent?

What assistance, if any, was given to the parent? Did the parent request assistance?

What is your overall assessment of the visit?

Was intervention required at any time throughout this visit? If so, explain circumstances and result.

Did the parent engage the child in age appropriate activities identified to facilitate attachment?

Were observations discussed with the parent?

Have extended family, friends, or relatives been included in visitation or had contact with the child?

Is regular visitation occurring between siblings? How often? Where?

Have the parent and child had phone contact between visits?

If the visit didn’t occur in the parent’s home, were the reasons documented?

(Court ordered, safety risks, homeless)

If the visit occurred at the DCBS office and was not court ordered, did the Service Region Administrator or designee approve it?

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